Distal exposure of the internal carotid artery is technically challenging and often inaccessible from a standard lateral neck incision. The double mandibular osteotomy (DMO) technique is described as an adjunct for vascular exposure. To date, no case series within the literature explores the technical and functional outcomes. The purpose of this study is to report our institutional results for exposure of skull base carotid artery pathology.

Background: Anecdotal experience demonstrates the existence of patients with superiorly located carotid stenosis, neoplasms, or aneurysms where the mandible obstructs effective surgical access using standard techniques. As carotid pathology extends anatomically beyond the limits of standard operative technique, additional exposure becomes paramount to safely and effectively address the lesion. Double mandibular osteotomy (DMO) is one of several techniques to obtain additional exposure to high-carotid pathology; however, there is no large series to address the outcomes of patients undergoing this procedure. Methods: A retrospective case series was performed for all patients undergoing surgery for carotid pathology from 2011-2019 that could not be approached with standard cervical incision. The primary predictor variable was higheanatomic carotid pathology necessitating DMO. The primary outcome variable was early and late complications sustained by patients. Results: Fifteen patients met study criteria and underwent 16 DMOs to access high-carotid pathology including carotid stenosis (n = 8 patients), carotid aneurysm (n = 2 patients), and carotid body tumor (n = 8 patients). Two patients had dual ipsilateral pathology with one patient having both carotid artery stenosis and aneurysm, and the other patient diagnosed with carotid artery stenosis and carotid body tumor. One patient had bilateral carotid artery stenosis, each requiring high anatomic exposure for treatment. Early complications occurred in 8 patients. Five patients experienced significant dysphagia requiring enteral feeding, and 2 patients developed malocclusion directly related to the double mandibular osteotomy. One patient experienced contralateral cortical watershed infarcts. Late complications included one patient developing osteomyelitis of the mandible, and this patient also developed distal mandibular segment screw exposure. The comparison of the outcome groups for categorical predictor variables using Fisher's exact test detected no statistically significant differences for gender, hypertension, hyperlipidemia, type 2 diabetes, chronic obstructive pulmonary disease, tobacco use, chronic kidney disease, or cerebrovascular disease. For the continuous variable comparisons, independent-samples t-tests detected no difference between the complication groups for age, operative time, or years of follow-up. No significant differences were found between the groups for body mass index or intraoperative blood loss. Conclusions: The double mandibular osteotomy provides excellent exposure and surgical access to the distal internal carotid artery for repair of vascular pathology with acceptable outcomes and long-term complications compared with previously reported techniques. Because of the early complications realized with the DMO, we recommend the procedure for symptomatic patients with a high risk of failing medical therapy alone and not appropriate for endovascular treatment as well as those patients with tumors requiring surgical intervention.

Diabetic foot ulcers (DFUs) are a major burden on the health-care system. The purpose of this study is to investigate factors affecting the healing rate of DFU in a university wound care center. Records of DFU patients treated between July 2013 and February 2015 were reviewed. Demographics, comorbidities, wound characteristics, and treatment modalities including offloading, hyperbaric oxygen treatment, total contact casting, and bioengineered skin were investigated. All patients underwent weekly debridement regardless of treatment modality. A total of 114 patients ages 18 to 98 comprised the study population. Total contact casting was the only treatment associated with increased healing ( P = 0.02). Smoking ( P = 0.004) and deep vein thrombosis history ( P = 0.001) significantly decreased the likelihood of wound healing. Patients with past vascular event trended toward longer healing times ( P = 0.07). Total contact casting in combination with weekly wound debridement showed benefit in DFU wound healing, whereas patients with a history of deep vein thrombosis and smoking were less likely to heal.

Gene therapy shows promise in the treatment of vascular disease, but a formidable challenge has been delivery of genetic material in a safe and non-toxic way. Viral transfection comes with significant clinical implications in terms of safety, and there are still no FDA-approved gene therapy products. This has led to recent interest in developing alternatives to viral transfection that are low risk, predictable, and non-toxic. Biodegradable polymers have shown promise as one of these alternatives, but to date have been exclusively tested in human stem cells. Differentiated cell types would be prime targets for therapeutic gene modulation in the prevention of various disease processes. We aim to establish polymeric transfection as a method of gene therapy in cells of vascular origin. Human aortic smooth muscle cells (HASMC) were transfected with poly(B-amino ester) biodegradable polymers (Stemfect™) conjugated to fluorescently labeled GAPDH or negative control (NC) siRNAs. Increasing polymer and siRNA concentrations were tested for optimal transfection efficiency. Conjugate endocytosis was confirmed by fluorescent microscopy, and gene silencing was assayed by qPCR normalized to 18S. Cellular translocation of the bioconjugates was visible 24 and 48 hours after transfection beginning with a 1.3μl polymer: 200pmol siRNA conjugate. At 48 hours after transfection, efficient gene silencing was achieved in a polymer concentration dependent manner, independent of increasing siRNA concentrations. The highest rate of GAPDH silencing was 84±4% vs. NC (n=5, P<0.05), achieved with a 3.9μl polymer: 200pmol siRNA conjugate. HASMCs were successfully transfected using polymeric bioconjugates. Future studies will expand on this method of gene therapy for transfection of whole vessel segments and in vivo animal models of vascular disease. This may provide new clinical options for genetic therapy in the prevention of peripheral vascular pathologies.

Percutaneous mechanical thrombectomy can be an effective procedure performed with low morbidity. We have observed clinically significant pancreatitis after successful clot extraction by percutaneous; thrombectomy. Pancreatitis developed postoperatively in four patients who underwent thrombectomy at our hospital. Each patient experienced abdominal symptoms with serologic and radiographic evidence of pancreatitis <= 24 hours after thrombectomy. The presence of renal failure and extensive dot degradation seemed to be related. Two of the patients underwent surgery that potentially could have been avoided had the etiology of pancreatitis been known preoperatively.